Prior Authorization

How CMS can fix prior auth to put patients before paperwork

Andis Robeznieks , Senior News Writer

The Centers for Medicare & Medicaid Services’ (CMS) asked for suggestions on cutting administrative burdens on physicians and others in health care. The AMA’s 28-page response is chock-full of suggestions for positive change, but first sets its sight on prior authorization, the time-consuming cost-control process that often restricts or delays access to treatments, drugs and services that patients need.

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“For every hour of face-to-face time with patients, physicians spend nearly two additional hours on administrative tasks throughout the day,” AMA Executive Vice President and CEO James L. Madara, MD, wrote in the letter to CMS Administrator Seema Verma. “The increase in administrative tasks is unsustainable, diverts time and focus away from patient care, and leads to additional stress and burnout among physicians.”

Dr. Madara cited AMA research regarding how long physicians must wait for a prior authorization (PA) decision and how that delays patients’ access to care.

According to an AMA survey, 91% of physicians reported that PA can have a negative effect on clinical outcomes, 75% of physicians reported that prior authorization delays lead to patients abandoning treatment. Most alarmingly, 28% said PA has led to a serious adverse event such as hospitalization, disability or death for a patient in their care.

The AMA has worked with health insurers on reforming prior authorization. A consensus statement arose from that effort, but health plans have been slow to adopt its provisions. Dr. Madara called on CMS “to take a leadership role” in developing a strategy to address PA concerns included in the consensus statement.

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Among other things, policy changes should:

  • Selectively apply PA to only “outliers” (versus broadly across all physicians).
  • Eliminate “low-value PA,” and stop applying it to services with high approval rates.
  • Improve communication regarding PA requirements, including the clinical basis for prior authorization.
  • Protect continuity of care for patients who enroll in new plans or when plans change PA requirements.
  • Automate PA processes to improve transparency and efficiency while maintaining physician oversight of payer access to data in a patient’s electronic health record.

The letter also addresses the AMA’s serious concerns regarding the CMS final rule allowing Medicare Advantage plans to use step therapy protocols that require patients to try and fail certain treatments before being allowed access to other, potentially more effective treatments.

Recommendations in this area include:

  • Requiring plans to publicly disclose in a searchable electronic format all drugs and services subject to PA, step therapy, formulary restrictions and quantity limits and to provide this information to vendors to be displayed in EHRs.
  • Prohibiting plans from requiring patients to retry therapies that failed under previous plans.

More recently, in a letter signed by 105 physician organizations, the AMA applauded CMS for listening to doctors’ concerns and considering prior authorization reforms as part of its Patients Over Paperwork initiative. The letter cautions, however, that relying on technological aspects will not solve the problem and may even set the stage for wider use of PA.

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Insurers’ progress on fixing prior authorization is disappointingly slow

Support for bipartisan legislation

A similar letter was sent to members of Congress in support of a bipartisan prior authorization reform bill, H.R. 3107, “Improving Seniors’ Timely Access to Care Act of 2019.”

The bill is was introduced by Reps. Suzan DelBene, D, Wash.; Mike Kelly, R, Pa.; Ami Bera, MD, D, Calif.; and Roger Marshall, MD, R, Kan.

“This bipartisan legislation would help protect patients from unnecessary delays in care by streamlining and standardizing prior authorization under the Medicare Advantage program, providing much-needed oversight and transparency of health insurance for America’s seniors,” the letter states. “We urge you to join your colleagues in supporting this important legislation.”